Credit Application 

Business Name
Dba or T/A Name
Address
City, State, Zip
Years at address
Type of Business Business Started  (Mo./Yr.)
State Phone # Fax #
Business Banking References .

Account Number

Telephone
. Checking  . .
. Savings . .
. Loans/Leases . .
Trade References/ Suppliers Account Number

Telephone
. . .
. . .
. . .
Insurance Agency . .

Equipment Description

Equipment Cost
. .
. .

Supplier/Vendor

Vendor Telephone & Contact
. .
. .
Name:                        Title: Name:                        Title:
Address: Address:
City:                   State:      Zip: City:                   State:      Zip:
Home Telephone (    ) Home Telephone (    )
SSN# : SSN# :

The following information must be completed in full, and will be held in the strictest confidence. 
I authorize the release of all credit information requested by Midwest Equipment Sales Inc.

Signature:_________________________________________________Title:______________________

Print Full Name_______________________________________________________Date:_____________  

4377 N.-1200 E.
Grovertown In. 46531
Telephone 574-936-1400
Fax 574-936-1405
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